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Document Title: Drogset-JBJS-May06.shtml
Article Title: A Sixteen-Year Follow-up of Three Operative Techniques for the Treatment of Acute Ruptures of the Anterior Cruciate Ligament
Authors: Jon Olav Drogset, MD, Torbjørn Grøntvedt, MD, PhD, Ole Rasmus Robak, MD, Anders Mølster, MD, PhD, Annja T. Viset, MD and Lars Engebretsen, MD, PhD
Publication: Journal of Bone and Joint Surgery, American Edition
Date: June 2006
Volume 88, pages 944-952
Keywords: ACL reconstruction methods, patellar-tendon autograft, ligament-augmentation device (LAD, synthetic ACL graft), primary repair, comparison, long-term follow-up.
(Reference-denoting numbers appear in the same font and point size as the document text. As with all Knee Library documents, this article is provided in full-text form, complete with all figures and tables.)
Comments: This Norwegian study follows up on patients treated surgically for ACL injuries. The 16-year time span captures patients treated with no-longer-used techniques, most notably the ill-fated LAD (ligament augmentation device, a synthetic device which was later found to mechanically break down inside the knee and cause massive problems) and primary repair (i.e. suturing the torn ends of the ACL together). The surgeons found that the most successful reconstructions were those using the patellar-tendon (BTB) graft. (These surgeons use a slight variation of the standard patellar-tendon graft: they retain the remnants of the natural ACL and suture them to the graft. This method may bring a slight advantage over removing the entire natural ACL stumps because the flared-end contouring of the natural ACL seems to be preserved.) It would have been interesting if the authors would have done hamstring-graft ACL reconstructions too, just to provide a comparison standpoint with the patellar-tendon reconstruction. (This article includes a commentary by Cohen and Fu.)
Abstract
Background: This study compares three surgical procedures that we used in the past to treat ruptures of the anterior cruciate ligament: acute primary repair, acute repair augmented with a synthetic ligament-augmentation device, and acute repair augmented with autologous bone-patellar tendon-bone graft.
Methods: This is the third report on a group of patients who were randomized to the three different procedures between 1986 and 1988. There were fifty patients in each group. The patients were evaluated prospectively at one, two, five, and sixteen years with use of the Tegner activity score and the Lysholm functional score. Stability of the knee was assessed with clinical examination and with use of the KT-1000 arthrometer.
Results: One hundred and twenty-nine (88%) of the 147 patients who were available for follow-up completed the study. Eleven patients (24%) who had a primary repair, four patients (10%) who had repair with a ligament augmentation device, and one patient (2%) who had augmentation with autologous bone-patellar tendon-bone graft underwent anterior cruciate ligament revisions between the primary operation and the sixteen-year follow-up examination. The rate of revision was ten times higher in the group that had primary repair than in the group that had repair with bone-patellar tendon-bone graft (p = 0.003). In the remaining patients, those who had repair with a bone-patellar tendon-bone graft had significantly more stable knees than those who had repair with a ligament augmentation device, as measured by the Lachman test (p = 0.026). Nine (11%) of the eighty-five patients for whom data were available had osteoarthritis in the primarily reconstructed knee, and three patients (3.5%) had osteoarthritis in the contralateral knee at sixteen years (p = 0.001); no difference was noted among the three groups. The mean Lysholm score at sixteen years was 88 points for the knees that had primary repair, 85 points for those that had repair with the ligament augmentation device, and 90 points for those managed with a bone-patellar tendon-bone graft (p = 0.286).
Conclusions: At long-term (sixteen-year) follow-up, the rate of revision anterior cruciate ligament surgery is much higher following primary repair than after primary repair augmented by a bone-patellar tendon-bone graft. It can be expected that approximately 10% of patients undergoing anterior cruciate ligament reconstruction acutely will have osteoarthritis develop in the reconstructed knee. We no longer perform any of these surgical techniques as open procedures.
Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.
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